Is pain a physical event or a psychological event?
Pain myth is America’s particular form of voodoo. It can be compared to Haitian juju and Brazilian black magic. We say American because the rest of the world has been slow to endorse the street science and bohemian medical theory which regularly replace sound research in the populist press. It is as if knowledge about fundamental pain chemistry has been outsourced to populations willing to cede the right to declaim about pain to scientific organizations in Canada, England, Germany, and elsewhere.
The blessed exceptions to this are the enclaves of brilliant clinicians and pain chemists in the U.S. who have the misfortune to speak of a common problem, pain, in a language which is utterly beyond that of the common man and disturbs his most basic assumptions. Like race theory which found blacks inferior, the pain patient is adjudged defective in character and below standard in motivation, in a measure directly correlated with the severity of the pain.
The patient is caught somewhere in the middle between society’s scientific blossom and society’s quasi-religious superstitions about a highly technical area. There is a segment of the American mind, hermetically sealed, whichs demands egalitarian science, as if science and politics are all the same. They wish to lobby for data which corresponds to their political and religious prejudices about those with pain and to solve the mystery of neurochemistry by a vote. As Jefferson and Madison declared, “The only cure for the evils of democracy is more democracy”. We therefore claim the privilege of speaking out in defense of those struggling with central pain.
When the Pilgrims arrived at Plymouth Rock, mental illness or oddity was considered evidence that someone was a “witch”. It was easy to prove these accusations, since “witch” signs were broad enough to sweep in almost anyone having a bad day. The Calvinistic ministers believed only 144,000 people would go to heaven, so that left quite a few candidates for the other place, some of whom just HAD to be witches. It was a social pejorative with no particular link to religion, science, or anything more than a disapproving neighbor. Today we think Halloween is an amusement for children. In those days, it was serious business. It is one more chapter in the sorry way the human race views those who are different. Central Pain is about as different as you can get. Will we find tolerance? Not until the neuroscientists cram it down society’s throat, we fear.
Many years ago, it was fashionable for doctors to think infertility was psychological. It is probably not possible to find a woman who was treated for it thirty years ago who was not told her problems were due to “nerves” or the inability to “relax”. However, as medicine grew smarter, it became possible to surgically open blocked fallopian tubes, and to enhance male fertility as well. The pregnancy rate climbed from twenty percent to above ninety percent. Are we to conclude from this that as medicine grew in knowledge, women just happened to relax, and that the INCREASE in pregnancy was also due to “nerves”?
Pain sits in the same relative position medically. Medical and ecclesiastical McCarthyism are still at hand. Hypervigilant accusators are in a witch hunt for some blameable attribute in the pain sufferer, generally some weakness in the mental apparatus (eg. “malingering”) or in the spiritual performance (ie. pain is god’s will). The more things change the more they stay the same. Critical, fixed ideas have never been the friend of enlightenment.
The harshness of direct contempt sometimes appears in the kinder guise of a psychiatric formula, one component of which is a method for pain relief. Political explanations for pain are not unpopular and infinitely easier for the public to grasp than the heavy chemistry of neurons. Whatever the formula du jour is for pain, be it meditation, special activities, or denial, it will lay heavy emphasis on the charisma of the formulator and considerable weight on some blameworthy trait that must be corrected in the pain patient. None of this emphasis on the context of pain is of much interest to the modern scientist, and it should not concern us here.
It is true that sensation does not occur in a psychological vacuum. Adrenalin, and its big brother Angiotensin, can fire up the body and make things happen. However, this “firing up” generally reduces pain, rather than activating it.
The taste of saltiness may be reduced or even eliminated by a life threatening situation. This does not mean that “saltiness” is psychological. Medicines which activate the VR-1 channel (now known as the TPRV-1 channel), such as capsaicin, predictably cause pain in rats and other animals, including humans. Drugs such as resiniferatoxin which eliminate the VR-1 channel, eliminate the chronic pain of nerve injury, leaving normal (nociceptive) pain intact.
Psychology is not particularly evident during testing for VR-1 pain. It is an equal opportunity pain channel, available to minds both neurotic and “normal”. However, the mental setting does affect the perception of any sensation. Thought processes are not the only context for sensation. Environmental variables also provide a context. Colors are more vivid with a background of their complimentary color. Thermal sensation is influenced by the ground state temperature of the skin prior to touching something. There is no rational objection to stating that sensation is affected by context.
This is quite a different matter from concluding that the physiologic event of pain is CAUSED by psychology. Context is not the primary process. The firing of VR-1 and Nav1.3 are part of the primary pain process, not mere context. The psychological consequences of action potentials and brain environments which affect the recognition of nerve firing should not be confused with the primary events of pain. This would ignore more than a hundred years of scientific research.
If we observe a person who is in severe pain, this does not mean that person is doing a poor job of using psychology to suppress the pain. Quite the opposite may be true. Because of the vital necessity of deflecting really severe pain, the subject may be resorting to extraordinary mental distractions in order to lessen pain, or to combat the depression which normally flows from prolonged terrible pain.
With little effort, the psychological consequences of torture of all varieties are also recognized in the severe CP case. Although many terrible tortures exist, there is little to suggest that physical pain from nerve injury falls short of the worst of them. Dehumanization, a sense of isolation from God, and agony are all there in severe CP.
The irrationality of pain literature is shown by the fact that there are only two sides, For and Against. The popular literature is Against, and the scientific literature is For. How did we get here. Why is there no middle ground? It can only be due to the abdication of responsibility by the social scientist, the religious leader, and the psychiatrist in failing to highlight the phenomenal difficulty of living with severe pain. Medicine does not leave it to the seriously ill to write literature on their own illness. We who have it are prevented from examining our situation too closely by the tremendous demands of our own pain.
Those who scrutinize society for the slightest jot of disadvantage in sex, race, or religious persuasion, examine instead the struggling individual when it comes to pain, and give society blanket immunity for its neglect. (What else can we call “meditation treatment” for severe pain except “neglect”?) Cotton Mather is with us still, seeking out those guilty of the onerous sin of pain. It is hardly fair to ask the Central Pain sufferer to articulate her own plight. Clarity requires some distance and central pain is the polar opposite of distance. One is IN the pain, and in a very real sense, the pain is In the person. The pain garbles the thought process, the identity crumbles, and the meaningless suffering that remains may lead to observation but certainly not insight.
There are very few studies which explore the psychological consequences of prolonged severe central pain, but it would be foolish to claim these destructive injuries do not exist, aplenty. It is time to quit making old fashioned claims about “nerves” causing pain, in the traditional sense of the meaning of “nerves”. Such ideas are inherited from an era of ignorance. It is time to start claiming instead that nerves do indeed cause pain, in the VR-1 sense. The VR-1 calcium channels cause pain in any animal in which they are activated, including humans, regardless of the psychological context. Thalamic or perithalamic injuries leading to central pain are not the areas of psychological emotion. Injury to the thalamus commonly causes CP, but injury to the frontal cortex, the emotional center,does not do this commonly, if ever.
It is time to start doing something about VR-1. Once we learn how to do this, the talk about psychology causing pain will be replaced by talk about pain causing psychology.
Pain is a reaction to physical events, not a consequence of poor mental hygiene or subconscious negative feelings. Whether we use a hammer or capsaicin to demonstrate this, the conclusion is the same. As therapists and doctors, we should be concerned with what mechanisms can BLOCK pain, rather than writing the whole process off to “nerves”. Speaking of “nerves” begs the question, and is inaccurate semantics. Psychology is secondary, not primary. It is not perverse or weak to experience suffering when the pain apparatus is actually firing.
One of the pain notions postulates that pain is more or less constant in the brain and pain represents a failure of the inhibitory mental processes, making anyone in pain a psychological failure. There is no evidence to suggest that the nervous system is raging in pain all the time, and that perceived pain is a failure in brain inattentiveness, nor that pain is a release of psychological distress.
Pain can be measured at its inception, whether central or peripheral in origin and in the higher VPM/VPL receptive centers in the thalamus. Nerve injury causes volleys and changes in the brain which can be seen on PET scans and functional MRI. That these changes are also observed in the cerebellum, which was traditionally associated with MUSCLE function, was first proved by Dr. Carl Saab, who has written elsewhere at this site. The cerebellar changes are consistent with the claim of muscle pain in CP patients This metabolic hyperreactivity is not seen in normal individuals.
Of course pain is due to nerves. This does not mean it is due to “nerves”.